ARFH VISITOR APPLICATION

The following questionnaire is designed to help us accommodate you better. The information you give is strictly confidential. The results of this form will be viewed only by the abbot, Ajahn Punnadhammo and the board member responsible for organizing the visitorls schedule. We do not share this information with any third parties.

About You
Your full name *
Email *
Town and Province or State
Occupation
Date of Birth day month year
Gender Woman Man Other   *
Emergency Contact - Name, Number and Relationship *
About Your Visit
Dates of Proposed Visit *
Possible Range of Alternate Dates *
Are You Interested in Serving as a Steward? Yes
If Needed
No
How will you be travelling to Arrow River? Driving
Airplane
Bus
Cell Phone Number
About Your Practice
If you have previously done retreats here or elsewhere please list starting with the most recent.
where? how long?
where? how long?
where? how long?
where? how long?
Indicate your current practise, if any
Have you previously visited Arrow River? YES NO
If so, when and in what capacity?
About Your Mental and Physical Health
Have ever been diagnosed with a psychological condition? Yes No
If so, describe the diagnosis, treatment and dates.
Are you currently taking any medications for physical or psychological conditions? Yes No
If so, please list each medication and the condition it is being used to treat.
Do you have any physical challenges that might make it difficult to deal with the rustic conditions here? Yes No
If so, please describe
Describe any present circumstances which might be placing you under additional stress or make meditation difficult for you (e.g., recent loss of a loved one or job, substance abuse, fasting)
Anything to Add?
Please add any additional information or comments that you think might be useful

By submitting this form you are agreeing to the following statements:

"I realize that a meditation retreat at ARFH is a serious undertaking that will require my full mental and physical health and I affirm that I am fit to participate in it. I hereby certify that the above information is true to the best of my knowledge."

"I agree that the Arrow River Forest Hermitage is not liable for any risk I might assume while visiting."

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